The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

Inpatient Management

Dean R. Hess, PhD, RRT Sunday, November 3, 1996

Impaired lung function can lead to respiratory failure requiring hospitalization, and occasionally intubation and mechanical ventilation. The purpose of hospitalization is to manage the patient's acute decompensation and co-morbid conditions to prevent further deterioration. Indications for hospitalization of patients with COPD include: acute exacerbation characterized by increased dyspnea, cough, sputum production; new or worsening cor pulmonale unresponsive to outpatient management; invasive surgical or diagnostic procedures that may worsen pulmonary function; a co-morbid condition that has worsened pulmonary function. Discharge criteria for patients with COPD include: inhaled beta-agonist required no more frequently than every 4 hrs; patient is able to walk across room; patient is able to eat and sleep without dyspnea; reactive airway disease under control; patient stable off parenteral therapy for 12 - 24 hrs; stable arterial blood gases for 12 - 24 hrs; patient fully understands correct use of medications; follow- up and home care arrangements are complete; patient, family, and physician are confident patient can manage successfully.

Drug therapy of inpatient COPD includes the use of beta_{2}-agonists, anticholinergics, theophylline, steroids, antibiotics, and sedation and pain management. A beta_{2}-agonist aerosol is usually given as the first step in the management of acute, severe COPD. Anticholinergic aerosols are often favored when the history indicates poor responsiveness to beta-agonists, and combination therapy with beta_{2}-agonists and ipratropium can be used. Theophylline may be added if aerosol therapy cannot be given or is inadequate. Corticosteroids may be useful if there is an asthmatic component in a patient who demonstrates responsiveness to beta-agonist therapy. Abnormal mucus usually provides a rationale for a course of antibiotic therapy. Sedation and pain management can be used in patients with COPD and the dosage slowly increased over several days to achieve the desired effect.

Most measures for mobilization of airway secretions in hospitalized patient with COPD lack adequate investigational support (e.g., chest physiotherapy, positive expiratory pressure, bland aerosol therapy, etc.). Research efforts should be focused on methods that are effective and inexpensive, including patient education and techniques which can be self-administered using low-cost equipment.

Nasal or oral intubation remains the primary approach to assisted ventilation in patients with acute exacerbations of COPD. The mode of mechanical ventilation should be determined on the basis of institutional experience and perceived patient benefit. The use of noninvasive modes of positive pressure ventilation is showing promise to avoid intubation of patients with COPD.

Oxygen therapy is commonly required for hospitalized patients with COPD. The most common oxygen delivery device in the hospital setting is the nasal cannula. The goal of oxygen therapy is correction of hypoxemia to a PaO_{2} > 60 mm Hg or SaO_{2} > 90%. Although it is recommended that PaCO_{2} and pH be monitored when titrating oxygen therapy, patients receiving oxygen sufficient to raise PaO_{2} to 60 mm Hg usually will not experience CO_{2} retention or acute respiratory acidosis.

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